This document provides an extensive overview of shoulder anatomy, common injuries, and associated conditions, focusing on the glenohumeral joint and its mechanics. It discusses differential diagnoses, clinical history, and physical examination techniques relevant to shoulder pain, as well as specific tests and symptoms related to various shoulder pathologies. A thorough understanding of the musculature, joint stability, and motion are emphasized to aid in diagnosis and treatment planning.

1. DR. PRUTHVIRAJ NISTANE
Deptt. Of Orthopaedics,Unit -2
Govt. Medical College and
Rajindra Hospital, Patiala

2.  Pertinent anatomy
 Differential diagnosis
 Clinical history
 Physical examination
 Common shoulder injuries

3.  Shoulder pain: a common
complaint
o More common causes in
adults
o Peak ages 40-60
o Impingement syndrome
o Rotator cuff problems
o Frozen shoulder
o 8-13% of all athletic injuries

4.  3 Bones
 Humerus
 Scapula
 Clavicle
 3 Joints
 Glenohumeral
 Acromioclavicular
 Sternoclavicular
 1 “Articulation”
 Scapulothoracic

5.  Humerus
 Head
 Greater tubercle
 Lesser tubercle
 Intertubercular(bicipital)
groove
 Deltoid tuberosity

6.  Scapula
 Angles
 Superior
 Inferior
 Lateral
 Glenoid
 Acromion
 Coracoid
 Scapular spine
 Subscapular fossa
 Supraspinatus fossa
 Infraspinatus fossa

7.  Glenohumeral joint
 “Balland socket” vs “Golf
ball and tee”
 Verymobile at cost of
stability
 45% of all dislocations
 Joint
stability depends on
multiple factors

8.  Glenohumeral joint
 Passive stability
 Joint conformity
 Glenoid labrum (50%)
 Joint capsule
 Ligaments
 Bony restraints

9.  Muscles
Deltoid
Trapezius *
Rhomboids *
Levator scapulae *
Rotator cuff
Teres major
Biceps
Pectoralis muscles *
Serratus anterior *
 * Scapular stabilizers

10.  Rotator Cuff Muscles
S – Supraspinatus
I – Infraspinatus
t - Teres minor
 S- Supscapularis

11.  Bursae
 Subacromial
(Subdeltoid)
 Subscapular
 Subcoracoid
 Coracobrachial
 Axillary recess

12.  Neurologic
 Nerve roots
 Brachial plexus
 Peripheral nerves

13.  Coordinated
shoulder motion
 Glenohumeral
motion
 Acromioclavicular
motion
 Sternoclavicular
motion
 Scapulothoracic
motion Scapular-humeral rhythm

14.  Impingement syndromes Other arthritic disease
 Subacromial bursitis – Septic
 Rotator cuff tendinopathy
– Tubercular
 Rotator cuff tear
 Biceps tendinopathy – Rheumatoid, Gout, SLE
 Adhesive capsulitis – Septic, Lyme, etc.
 SC joint arthritis, sprain Avascular necrosis
 AC joint arthritis, sprain Neoplastic disease
 Glenohumeral joint OA Thoracic outlet syndrome
 Instablity
 GH dislocation CRPS
 GH subluxation Myofascial pain
 Labral tear (e.g. Bankart, SLAP, Referred pain
etc.)
 Clavicle fracture – Cervical radiculopathy
 Proximal humerus fracture – Cardiac
 Scapular fracture – Aortic aneurysm
– Abdominal / Diaphragm

15. Diagnosis Primary Care Age
%
Subacromial Impingement 48-72 23-62
Syndrome
Adhesive Capsulitis 16-22 53
Acute Bursitis 17 -
Calcific Tendonitis 6 -
Myofascial Pain Syndrome 5 -
Glenohumeral Joint Arthrosis 2.5 64
Thoracic Outlet Syndrome 2 -
Biceps Tendonitis 0.8 -

16. History

17. oAge - 2nd & 3rd decades instability
4th & 5th decades impingement, frozen shoulder, inflammatory
joint disease
6th decade onwards rotator cuff tears , degenerative joint
disease
oPain
oWeakness
oDeformity
oInstability
oLocking / Clicking / Clunking
oSport / Occupation
oPrevious treatments
oAlleviating / Exacerbating
oAcute vs. Chronic
oTraumatic vs. Overuse
oHistory of prior injury
oMechanism of injury

18. • ACJ pain - well localised
• Cervical pain - Neck pain, pain over trapezius or
medial border of scapula
• Neurogenic Pain - Assoc pain in wrist or hand +/-
parasthesiae
• Subacromial and rotator cuff pathology - Poorly
localised pain from deltoid region usually
• Night pain - often rotator cuff disease, glenohumeral
arthritis and frozen shoulder
• Acute calcific tendonitis - Sudden onset excruciating
pain is typical of reorptive phase of
• Painful arc - Pain occurring in part of the range of
shoulder abduction is termed

19.  Any history of trauma?
 Was shoulder dislocated?
 How many dislocations since then?
 Was dislocation spontaneous? If atraumatic
dislocation is there history of joint laxity?
 Painless clicks in the shoulder are common
and usually have no significance

20.  Following traumatic event - important to
exclude brachial plexus injury
 May be due to pain (would examine with
local anaesthetic joint examination in
shoulder clinic)

21.  Restriction of both passive and active
movements
 Usually associated with frozen shoulder,
osteoarthritis, rheumatoid arthritis, chronic
dislocation and cuff tear

22.  Undressupto waist
 Compare both sides
 Inspection
 Palpation
 Measurements
 Active & passive ROM
 Strength testing
 Special tests
 Distal neuro-vascular
status, Lymph nodes

24.  Front & Back
 Above
 Axilla
 Laterally
 Asymmetry
 Attitude
 Obvious deformity
 Swelling
 Skin condition
 Ecchymosis

25.  Height of shoulder & scapulae
 Muscle atrophy / contractures
 Supraspinatus
 Infraspinatus
 Deltoid
 Contour of shoulder
 Neck
 Epicondyles

27.  At rest & with movement
 Bony structures
 Joints
 Axilla
 Soft tissues
 Codman’s method
o Swelling ,crepitus
o Irregularitis
o Local temperature
o Local tenderness
o Lymph nodes

28.  Surface Anatomy
(Anterior)
AC joint
 Manubrium
 Clavicle
biceps
 SC Joint
 Acromion process
SC joint
 AC Joint
 Deltoid
 Coracoid process
 Pectoralis major
 Trapezius
 Humeral head
 Greater tubercle
 Lesser tubercle
 Biceps (long head)

29.  Surface Anatomy
(Posterior)
Supraspinatus
 Scapular spine
 Acromion process
 Supraspinatus
Infraspinatus  Infraspinatus
Inferior angle
of scapula
 Deltoid
 Trapezius
 Latissumus dorsi
 Scapula
 Inferior angle
 Medial border

31. 30° to coronal plane
 Forward flexion:
(160 - 180°)
 Anterior deltoid, Pectoralis
major, coracobrachialis
 Extension:
(40 - 60°)
 Latissimus dorsi,teres major,
posterior deltoid
 Adduction:
(45 °)
 Pectoralis major, latissimus
dorsi, teres major

32.  Abduction:
(180°)
glenohumeral rhythm (2: 1)
 By fixing the scapula with thumb and finger
try to quantify glenohumeral movement only
middle deltoid, supraspinatus
 Internal rotation:
(60 - 90 °)
subscapularis, pectoralis major, latissimus
dorsi, teres major; anterior deltoid
 External rotation: Apley Scratch Test
(40-60 °)
infraspinatus, teres minor; posterior deltoid
 Circumduction

33. Abduction
•60°-120° painful – impingement
syndrome
•Whole range painful – arthritis of
GH joint,acute tendinitis
•>90° painful – AC joint arthritis
•Upto 30° difficult – rotator cuff
tear
•Restricted movements – Frozen
shoulder, ankylosis

34. Abduction with Adduction with
external rotation internal rotation
Quick screening test

35.  scapular motion
• Scapular dyskinesis (Scapulothoracic
dysfuntion)
 Compare scapular motion through ROM on
both sides
 Wall push-ups
 Symmetrical
 Smooth
 Winging Medial winging results from injury to
long thoracic nerve,
 Lateral winging results from trapezius
weakness( accessory spinal nerve ).

36.  Test & compare both sides
 Be specific to muscle or muscle
group
 Grade strength on 0 → 5 scale
 0: no contraction
 1: muscle flicker; no movement
 2: motion, but not against gravity
 3: motion against gravity, but not
resistance
 4: motion against resistance
 5: normal strength

38.  Apparent lengths – from seventh cervical
spine to tip of radial styloid
 True length – angle of acromion – tip of
lateral epicondyle - tip of radial styloid
 Wasting
 Anterior and posterior axillary folds –
Bryants sigh
 Girth of axilla - Callaways test

41.  Hamilton ruler test
 Duga’s test

43. Intrinsic
– Subacromial bursa
– Rotator cuff muscles and tendons tears
– Biceps tendon
– Rotator cuff tendonosis
– Cuff thickening/bursitis
– Calcific tendinitis
– fractures
Extrinsic
– Instability / # – young
– Subacromial spurs – old

44. Between
– Acromion
– AC joint
– Coracoacromial ligament
– Coracoid process
– Humeral head
 Pain with activity above shoulder
height
 At night
 Painful arc of abduction – 60-120 degrees
 Positive impingement signs

45. Neer’s Impingement
Sign
– Arm fully pronated and
placed in forced flexion
– Trying to impinge
subacromial structures
with humeral head
– Pain is positive test
Neer’s Impingement test

46. Hawkin’s Sign
– Arm is forward
flexed to 90
degrees, then
forcibly internally
rotated
– Trying to impinge
subacromial
structures with
humeral head
– Pain is positive test

47.  Jobe's Empty can / full can test
test:
• arm abducted to 90, in the plane of the
scapula, 30° flexion and full internal
rotation (empty can) or 45°external
rotation (full can), elbow extended
• Patient resists downward pressure
exerted by examiner at patients elbow or
wrist.
• Muscle testing against resistance
• Weakness or insufficiency of
supraspinatus
• Tear / impingement

48.  Internal Rotation Resistance Stress
Test
 to differentiate between internal and
classic impingement
 Shoulder in 90 degrees of abduction
and 80 degrees of external rotation.
 A manual isometric muscle test is
performed for external rotation and
compared with one for internal
rotation in the same position.
More weakness in internal rotation - internal impingement
more weakness in external rotation - classic outlet impingemen

49.  Gerber Subcoracoid Impingement
Test
 impingement between the rotator
cuff and the coracoid process
 Shoulder flexed 90 degrees and
adducted 10 to 20 degrees across
the body to bring the lesser
tuberosity into contact with the
coracoid.
 Pain indicates coracoid
impingement

51.  Partial thickness tear
 Full (Complete) thickness tear
 Supraspinatus > Infraspinatus > subscapularis
 Reduced function and night pain
 Painful arc, gap may be felt
 May be due to:
 Impingement
 Degeneration
 Overuse
 Trauma
 Partial tears
 Conservative
 Complete tears
 Surgery

52. Rent Sign/Test
 Tests for a torn rotator cuff or rotator cuff
impingement
 Patient seated,palpate anterior to the
anterior edge of the acromion with one hand
while holding the patient’s flexed elbow with
the other
 The examiner passively extends the shoulder
while slowly rotating the shoulder into
external and internal rotation. The greater
tuberosity will be prominent and a
depression of about 1 finger width will be
felt if a rotator cuff tear is present.

53. Rent Sign/Test

54.  Resisted abduction with arms by side
 Jobe's Empty can / full can test test: arm
abducted to 90°, 30° flexion, in the plane
of the scapula and full internal rotation
(empty can) or 45°external rotation (full
can), elbow extended
 Patient resists downward pressure exerted by
examiner at patients elbow or wrist.

56. Drop-Arm Test
Abducted arm slowly
lowered
– May be able to lower
arm slowly to 90°
(deltoid function)
– Arm will then drop to
side if rotator cuff tear
Positive test
– patient unable to
lower arm further with
control

57.  Strength Testing
 Tests Supraspinatus
 Attempt to isolate from
deltoid
 Sitting
 Arms straight out
 Elbows locked straight
 Thumbs down
 Arm at 30 degrees
(in scapular plane)
 Attempts to elevate
arms against resistance

58.  Resisted ER with the arms by side
 Drop test:
 Shoulder in 90 degrees of
abduction and at almost full
external rotation with the elbow
flexed at 90 degrees. The patient
is asked to maintain this position
 The sign is positive if a lag or
“drop” occurs

59.  External Rotation Stress Test / swing
door test
 patient's arms by his or her side in neutral
flexion and abduction, the shoulders are
externally rotated 45 to 60 degrees.
 The examiner applies force against the dorsum
of the hands, attempting to rotate the shoulders
internally back to neutral while the patient is
asked to resist.
 Pain and weakness

61.  External Rotation Lag Sign
 The patient is asked to maintain the
position of maximal external rotation
actively as the examiner maintaining
support of the arm at the elbow.
 The sign is positive when a lag or angular
drop

62. Hornblower’s Sign (Patte Test)
 strength of the teres minor
 Abduct the patient’s arm to 90 degrees in
the scapular plane.
 Flexe the elbow to 90 degrees, and the
patient is asked to laterally rotate the
shoulder.
 A positive test occurs with weakness and/or
pain

63. Hornblower’s Sign (Patte Test)

64.  External rotation
 Tests RTC muscles that ER
the shoulder
 Infraspinatus
 Teres minor
 Arms at the sides
 Elbows flexed to 90 degrees
 Externally rotates arms
against resistance

65.  Gerber's lift off test:
 dorsum of the hand is placed
against the lower back.
 If the patient is unable to lift the
dorsum of the hand off the back
and push examiner's hand away
from 'hand behind back position'
the test is positive

66.  Internal rotation lag sign: inability to hold hand
away from the lumbar region in maximal internal
rotation

67.  Belly Press Test (Napolean sigh)
• patient presses the abdomen with the
flat of the hand and attempts to keep
the arm in maximal internal rotation
• If the strength of the subscapularis is
impaired, maximal internal rotation
cannot be maintained, the patient
feels weakness, and the elbow drops
back or can only exercise abdominal
pressure by a retropulsion of the arm
and by bending the wrist

68.  Modified Belly Press Test (Quantitative)

69.  Internal rotation
 TestsRTC muscle that IR
the shoulder
 Subscapularis
 Arms at the sides
 Elbows flexed to 90
degrees
 Internally rotates arms
against resistance

70.  Injury to long head of
biceps tendon
 Typically an overuse
injury
 Repetitive (overhead)
lifting
 Impingement

71.  AERS test:
(Abduction External Rotation Supination test)
. Pt feels pain on resisted supination in this position.
 Tenderness over antero-superior deltoid bulge on
shoulder rotations

72.  Forward flex shoulder to
about 90°
 Abduct shoulder to about
10°
 Elbow - extended
 Arm in full supination
 Apply downward force to
distal arm
 Pain is positive test
 Bicepital tendinitis, SLAP
 Weakness without pain:
muscle weakness or
rupture

73.  Elbow flexed to 90°
 Start in pronated position
 Active supination & flexion
against resistance
 Palpate biceps tendon
 Pain or painful pop is
positive test
 Tendonosis
 Subluxation

74.  Deltoid: resisted abduction over 30º
 Serratus anterior: "Winging" test

76. Failure to keep humeral
head centered in glenoid
Dislocation
– Complete disruption of
joint congruity or
alignment
Subluxation
– Partial or incomplete
dislocation
Laxity
– Slackness or
looseness in joint
– May be normal or
abnormal

77.  Sulcus Sign
 Arm relaxed in
neutral position
 Arm pulled downward
at wrist
 Positive test is a
visible sulcus at infra-
acromial area
 Compare to
contralateral side

78.  Feagin maneuver -

79.  Apprehension Test
 Shoulder abducted to 90°
 Slight stress to humeral head
directed in anterior direction
 While externally rotating
shoulder
 Positive test is apprehension
due to feeling of instability or
impending dislocation
 Beware if false positives
 Augmentation test – apply
anteriorly directed force by
extending shoulder

80.  Relocation Test
 After a positive
apprehension
 Apply posteriorly
directed force over
externally rotated
humeral head
 Positive test is relief of
apprehension
 Anterior release test

81. subluxation tests: (Load and Shift Test)
 Anterior subluxation test: abduction and external
rotation "apprehension test" with thumb posteriorly
and fingers anteriorly over humeral head
Shoulder
Latchman
 Posterior subluxation test: internal rotation,
adduction, flexion and push posteriorly

82.  Apprehension Test
Flex and internally rotate the shoulder
 Circumduction Test
Circumduction in abduction

83. Tear in glenoid labrum
Usually due to instability
SLAP Tear (Superior Labrum
Anterior to Posterior)
– Superior labral tear
– Fall on outstretched hand or
shoulder
– Rotator cuff tendonosis or
tears
Bankart Lesion
– Anterior-inferior labral tear
– Anterior shoulder dislocation
/ subluxation

84.  O’Brien’s Active Compression Test
 Labral, AC, or biceps pathology
 Arm flexed to 90°
 Arm cross-arm adducted 10-15°
 Elbow extended
 Max pronation
 Resist downward force
 Positive test if painful
 Beware location of pain
 AC
 Biceps
 Internal +/- click

85.  For labral pathology
 Repeat testing with
 Max supination
 Should be pain free

86.  Labral Tear: Crank Test
 Abduct arm to 90-120°
 Stabilize shoulder
 Elbow secured with one hand
 Axially load with ER / IR at
Shoulder shoulder
.
Apley’s
 Positive test: audible or
painful click / catch / grind

87.  Jobe Apprehension-Relocation Test
 to distinguish between primary impingement and
secondary impingement due to anterior
instability
 patient supine, the arm is abducted 90 degrees
and externally rotated, which produces pain
 Posteriorly directed force to the humeral head,
relocating it in the glenoid, does not change the
pain in patients with primary impingement, but
relieves the pain in patients with instability
(subluxation) and secondary impingement

88. Jerk Test
 Tests for posterior instability/ torn posterior or
posteroinferior labrum.(reverse Bankarts)
 The examiner grasps the elbow with one hand
and the scapular with the other and elevates the
patient’s arm to 90° of abduction and internal
rotation
 An axial compression load to the humerus
through the elbow maintaining the horizontal
position.
 The compression force is maintained as the
examiner moves the arm into horizontal
adduction.
 A positive test is indicated by sharp pain in the
shoulder with or without a clicking sound

89. Jerk Test

91. Biceps Load Test
 Integrity of the superior labrum.
 supine with shoulder abducted to 90 degrees and
externally rotated, and forearm is supinated.
 externally rotates the shoulder until the patient
becomes apprehensive. Rotation is stopped and
resisted elbow flexion while in this position.
 Pt worsens and apprehension remains, the test is
considered positive.
 If apprehension decreases or the patient feels
more comfortable, the test is negative for a SLAP
lesion.
 Biceps Load Test 2: shoulder abducted to 120 *

92. Biceps Load Test

94.  Capsule sticks to humeral head
 IR  Flexion  ER
 GLOBAL RESTRICTION ROM
 NIGHT PAIN
 Cause often unknown – but beware diabetes
 Self limiting condition (6mth-2yrs).
 Painful
 Restrictive
 Resolution

96. – Typically due to fall
onto tip of shoulder
(acromion)
– Arm tucked into side
• Pain with activity (esp
overhead, or weight
training)
• AC Jt tender
• Crepitus/clicking
• Deformity
– Treatment depends
on type

98.  Arm flexed to 90°
 Arm adducted to > 45°
 Hyperadduct shoulder
(down on elbow)
 Positive test is pain in AC
joint
 Watch out for false-
positives
 Where is the pain?

100. AC Shear Test
 To test for acromioclavicular pathology
 The patient is in sitting position while the
examiner cups his or her hands over the
deltoid muscle with one hand on the clavicle
and the other on the spine of the scapula.
 The examiner then squeezes the heels of the
hand together.
 Abnormal movement is a positive test.

101. AC Shear Test

102.  Where is the pain?  Neurology
 over deltoid – think  C5 deltoid (S, M),
shoulder biceps (R)
 over traps – think  C6 thumb (S), biceps
neck (M), BrRad (R)
 Radicular pain –  C7 digit 3(S), triceps
think neck (M, R)
 C8 digit 5(S), FDP/S
(M)
 Examine  T1 medial elbow (S),
 Cervical spine ROM finger abduction (M)
 Radial nerve
 Ulnar nerve
 Median nerve

103.  Assess cervical spine to see if neck
movements recreate shoulder symptoms
 In full extension of C spine nose parallels the
floor and in full flexion chin should rest on
chest
 Lateral rotation approx 80o
 Lateral flexion 40o

104.  Sensation dermatomes C4 toT2
 Power around elbow, wrist and hand
 Shoulder power tested separately
 Test peripheral nerves, esp. Axillary nerve
 Biceps and triceps reflexes
 Tests for thoracix inlet syndrome
 Radial / Ulnar pulses

106.  AC joint
 Subacromial space
 Glenohumeral joint
 Biceps tendon (long head)

107.  Plain XR
 AP (IR and ER)
 Axillary lateral view
 Supraspinatus outlet
view
 AC joint

108.  U/S scan
 Cuff tears,
tendinopathy, bursitis
 Undercalls cuff
pathology
 Can inject at the
same time

109.  Bone scan  MRI
 Esp
if referring for  Cuff tears
ACJ surgery  MRA
 CT arthrogram  Labral pathology and
 Particularly
useful instability
for recurrent
instability
 Arthrogram
 Arthroscopy
 Joint aspiration

110.  THANK YOU !!!!